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Date run 10/8/2015 11:55:38AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 10/8/2015 <br />Record Selection Criteria: Facility ID FA0010773 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br />Owner ID OW0007962 Case Number: H06027 New Owner ID <br />Owner Name RIDER, ALLEN JR <br />Owner DBA CHEROKEE MUFFLER & RADIATOR <br />Owner Address 4035 N WILSON WAY 1 <br />STOCKTON, CA 95205-2466 <br />Home Phone Not Specified <br />Work/Business Phone 209-922-4674 <br />Mailing Address 4035 N WILSON WAY, STE 1 <br />STOCKTON, CA 95205-2466 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0010773 10183807 <br />Facility Name CHEROKEE MUFFLER & RADIATOR <br />Location 4035 N WILSON WAY STE 1 <br />STOCKTON, CA 95205-2466 2 <br />Phone 209-462-2610 x <br />Mailing Address 4035 N WILSON WAY, STE 1 <br />STOCKTON, CA 95205-2466 <br />Care of RIDER, ALLEN JR <br />Location Code 99 - UNINCORPORATED P Alt Phone <br />BOS District 002 - MILLER, KATHERINE Fax <br />APN 13202009 EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017773 New Account ID: <br />Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br />Account Name CHEROKEE MUFFLER & RADIATOR (Circle One) <br />Account Balance as of 10/8/2015: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PRO520844 EE0000006 - HAZA SAEED Active Y N A;� D <br />2220 - SM HW GEN <5 TONS/YR PR0514411 EE0000005 - FATINAH ZAREEF Active Y N A D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513061 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2226 - CaIARP PROGRAM PR0514864 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510773 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />3122 - STORMWATER INSPECTION - AUTO SHOP PR0522998 EE0004636 - GARRETT BACKUS Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0536925 EE0004636 - GARRETT BACKUS Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date / ! <br />Payment Type Check Number Received by <br />EHD Staff: Date ���/ /_ Account out: U5 Date !U <br />COMMENTS: / I� /l <br />U 1z 'J IK/ tom._ dC�Invoice # <br />ff <br />1-1" '4-, Iqc'-o f.%.15ti ("),-{ <br />